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CLINICAL ARTICLE
1
Department of Family Medicine, Faculty of Health Sciences, University of the Free
* Correspondence
Sciences, University of the Free State, PO Box 339, Bloemfontein 9330, South
Africa.
Email: steinbergwj@ufs.ac.za
This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1002/ijgo.12168
Abstract
deliveries.
termination between 2010 and 2013. The study group, comprising women with one
or more previous cesareans, was compared with a control group, comprising women
compared, including misoprostol use, termination duration, need for other methods
Results: The study group comprised 268 women: 231 (86.2%) with one and 37
(13.8%) with two previous cesareans. The control group comprised 266 women.
Incomplete abortion was recorded in 223 (85.4%) of 261 women in the study group
and 213 (80.4%) of 265 in the control group. The number of women with retained
placenta was higher in the study than in the control group (158/261 [60.5%] vs
146/265 [55.1%]; P<0.001). Severe bleeding was observed only in the control group
1 INTRODUCTION
In the past decade, cesarean deliveries have been increasing worldwide [14]. As a
result, the number of women seeking termination of pregnancy with one or more
uterine rupture is 0.07%; however, this can increase to 0.5% among women who
have had a previous cesarean [8]. Furthermore, women with an unscarred uterus
Medical abortion offers an alternative to surgical abortion. Labor induction is used for
for termination of pregnancy because of its effectiveness. The drug is also stable at
ambient temperature and less costly than other methods [1012]. Although
misoprostol is considered safe for second-trimester terminations, the safety of its use
Africa, has been established for more than 15 years and provides terminations under
weeks if a cesarean had been performed in the previous 24 months owing to the
possibility of complications. In 2009, this time interval was reduced to 18 months for
of scar (i.e. vaginal birth after cesarean) at term depends on various factors,
including an interval of at least 18 months between the previous cesarean and the
The aim of the present study was to establish the safety and efficacy of the local
In a retrospective analytical study, data were reviewed from women attending the
Reproductive Health Clinic, National District Hospital, Bloemfontein, South Africa, for
The study was approved by the Ethics Committee of the Faculty of Health Sciences,
University of the Free State, South Africa. Written approval from the hospital
authorities of National District Hospital was obtained to access patient files. All
information was handled confidentially. Individual informed consent was not deemed
woman included in the study group, the next patient in the register who underwent a
other operations that might cause uterine scarring was included in the control group.
None of the patients had a contraindication for prostaglandin use, or any other
The following misoprostol protocol is used at the Reproductive Health Clinic for
dose, followed by 200 g orally every 2 hours for three doses starting 3 hours after
the vaginal dose, up to a maximum of 1400 g (regimen 1). The waiting period is
24 hours after the first dose of misoprostol. If the abortion does not occur during this
no further misoprostol doses are given. If, after the second regimen, a further 24
hours have lapsed and the abortion has not occurred, the patient is given an
oxytocin infusion (20 IU in 1 L Ringers lactate) over 16 hours at a rate of 125 mL/h. If
the oxytocin infusion fails, a formal dilatation and evacuation (D&E) is done in theater
diclofenac sodium (75 mg). All women are assessed after the abortion to decide
since the last cesarean, and length of pregnancy in weeks. The period of
amenorrhea, when known, was used to determine pregnancy length and was
and 2), duration of termination, need for other methods (oxytocin, D&E, or MVA),
bleeding. The duration of the termination was measured from the time that the
content. The abortion was considered incomplete if the placenta was retained for
Data were analyzed using SAS version 9.3 (SAS Institute, Cary, NC, USA).
variables, and 2 or Fisher exact test for categorical variables depending on the cell
between the study and control groups was performed for the main outcomes. P<0.05
The study group comprised 268 women with one or more previous cesareans, and
the control group comprised 266 women without a uterine scar. Because of an
administrative error, one patient was erroneously initially included as a control, but
had actually had a previous cesarean delivery and as such was transferred to the
study group. Of the women in the study group, 231 (86.2%) women had one
Women in the study group were older than those in the control group (Table 1). The
median number of pregnancies (gravidity) and births (parity) were the same in both
groups, but the 25th percentiles differed (both P<0.001) (Table 1). There was a
difference of 1 week in median pregnancy length between the study group and the
control group (P<0.001) (Table 1). The total number of previous abortions was
slightly higher in the study group than in the control group, although the difference
was not significant (Table 1). For the study group, the median duration between the
Women with two previous cesareans were significantly older and had significantly
higher parity and gravidity than those who had one previous cesarean (P<0.001)
(Table 1). The median duration since the last cesarean for women with two
procedures was also significantly longer than that for women with one cesarean
(P=0.0409) (Table 1). The women in both subgroups were significantly older and had
higher parity and gravidity as compared with the control group (P<0.001 for all
The median time from induction to expulsion was 9 hours in both the study and the
completed between 7 and 12 hours, followed by 6 hours or less (Table 2). Most of
The rate of termination success by using regimen 1 only was significantly higher in
the study group than in the control group (P=0.0481) (Table 3). Few women in either
group needed oxytocin or D&E. Most women in the study and control groups
required an MVA. In both groups, at least 80% of the abortions were incomplete
(Table 3). The number of women with retained placenta was significantly higher in
the study group than in the control group (P<0.001) (Table 3). Severe bleeding was
observed only in the control group. There was no need for blood transfusion in either
In a logistic regression model adjusted for patient age, parity, gravidity, and length of
pregnancy, the significance of factors was similar to those observed in the univariate
comparison of the study and control groups: regimens 1 and 2, P=0.0602; oxytocin
P=0.0015; and incomplete abortion, P=0.1418. The logistic model could not be fitted
control group. Women with two cesareans had a higher incidence of retained
compared with the control group. No significant differences regarding outcomes were
found between women with one and those with two cesareans (Table 3).
4 DISCUSSION
The present study found a significant difference between the study group and the
control group in terms of age at time of termination, gravidity, and parity. The control
primigravidas. The latter variable, however, did not influence the outcomes. The
median duration between induction and expulsion was 9 hours in both groups. A
high percentage of women aborted in the first 12 hours after treatment initiation. The
success rate in the first 24 hours was 93.3% in the study group and 88.3% in the
control group. Previously reported success rates using misoprostol range from 71%
to 100% for women with an intact uterus [5,6,10,12,18], and from 74% to 90% for
women with a previous cesarean [2,46,18]. In the present study, all women in both
the study group and the control group eventually expelled the fetus using regimen 1,
termination on a more regular basis [57]. Studies on the use of misoprostol alone
among women with previous cesareans are limited, and a lack of randomized trials
makes it difficult to draw conclusions [5,6]. Despite the evidence that misoprostol is
The dose, route, and interval of misoprostol administration vary widely, from three to
some studies, the misoprostol regimen was supplemented with an additional rectal
dose when products of conception were retained [12]; in others, oxytocin was
complications [6]. The misoprostol regimen administered at the study clinic uses
In the present study, the median duration of termination was longer for women with
two previous cesareans than for those with one procedure. The median induction-to-
expulsion time was shorter than that reported by other authors [2,4,11,18], who
noted durations ranging from 14.5 to 42.6 hours using different regimens. In the
present study, the high-loading vaginal dose used in regimen 1 is likely to increase
the uterine response, leading to stronger contractions faster as compared with lower
doses.
gradually and reaches maximum levels after 7080 minutes, remaining high for at
least 4 hours [20]. After oral administration, the plasma level peaks at approximately
30 minutes, and declines rapidly with a half-life of 2040 minutes [20]. The vaginal
route is considered more effective than the oral route [18]. It has been found that a
Overall, there was a high rate of placental retention, with a higher rate in the study
group than in the control group. Dickinson [5] reviewed data from 720 women who
(200600 g). Of these women, 101 (14%) had at least one previous cesarean.
Similar to the present study, Dickinson [5] found a higher rate of placental retention
among women with a previous cesarean (41.6%) than among women with no
previous cesarean (34.4%). He proposed that the reason for the overall high rate of
retention might be low uterine contractility, because misoprostol was stopped after
fetal expulsion and a high proportion of women did not receive the complete dosage
(1400 g) of the first regimen. In the present study, retained placenta occurred more
often among patients with two previous cesareans than among those with one
The expulsion of uterine content was considered incomplete in 85.4% of the study
group and 80.4% of the control group in the present study. These values are higher
than those reported by Latif et al. [19], who found that surgical evacuation was
needed in 68.9% of terminations, although they used oxytocin infusion after fetal
expulsion. In the present study, the incidence of surgical evacuation was higher
among women with two previous cesareans than among those with one cesarean,
which occurred in 2.6% of women in the control group and none in the study group.
No uterine rupture was reported in either group. Similarly, Dickinson [5] reported no
uterine rupture in his review of women with or without previous cesarean deliveries.
In a study of 138 women, 31 of whom had three or more previous cesareans, Fawzy
and Abdel-Hady [4] used 200-g doses of misoprostol vaginally every 6 hours in the
first 24 hours, followed by 400-g doses every 6 hours. They observed one
occurrence of uterine rupture in the study group during hysterotomy. Gle et al. [2]
used 400-g doses of vaginal misoprostol every 4 hours in a study of 60 women with
one cesarean, 26 with two or more cesareans, and 193 control women. They
reported uterine rupture for three women, all of whom had either two or three
trimester termination [4,10]. The risk of uterine rupture is reported to increase when
The present study has some limitations. The data were gathered via a retrospective
record review with no prospective information. It was assumed that the local
scar complications might have been missed if clinical signs did not manifest in the
patients. The study excluded women who had been lost to follow-up. However, if no
complications were noted, it remains theoretically possible that they might have been
missed.
compared with control women, however, the local misoprostol regimen used was not
as efficient for women with previous cesareans, because more of these women had
placental retention. Larger studies are needed to improve statistical power. Although
maintained.
Author contributions
MCT conceived the study, developed the protocol, performed data collection, and
drafted the manuscript. WJS assisted with protocol development, analysis and
performed data analysis, and helped with data interpretation and manuscript
revision.
Acknowledgments
We thank Ms. T. Mulder, medical editor (School of Medicine, University of the Free
Conflicts of interest
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a
Table 1 Demographic and obstetric characteristics.
Characteristic All women (n=534) Study group (n=268)
Study Control group P One Two P
group (n=266) value cesarean cesareans value
(n=268) (n=231) (n=37)
Age, y 27 (24 24 (2030) <0.001 26 (2431) 30 (2733) 0.001
32)
Gravidity 2 (23) 2 (13) <0.001 2 (23) 3 (33) <0.001
Parity 1 (12) 1 (02) <0.001 1 (13) 2 (22) <0.001
Length of pregnancy, 14 (13 15 (1316) <0.001 14 (1316) 14 (1316) 0.9503
wk 16)
Duration since last 48 (33 46 (3176) 53 (4199) 0.0409
cesarean, mo 81)
Previous terminations 15 (5.6) 11 (4.1) 0.4326 13 (5.6) 2 (5.4) >0.99
a
Values are given as median (interquartile range) or number (percentage), unless indicated
otherwise.
Table 3 Outcomes.a